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Primary Care Physician
15-20 minutes

Primary Care Consultation Template Template

This GP consultation template, optimized for use with s10.ai, an advanced AI medical scribe, empowers general practitioners to efficiently document patient visits with precision. It features dedicated sections for patient history, examination findings, and treatment plans, ensuring a comprehensive overview of each consultation. Ideal for capturing detailed symptom descriptions, associated treatments, and pertinent past medical or family history, this template supports GPs in maintaining thorough records while managing multiple patient concerns. By streamlining the documentation process, it enhances patient care and encourages clinicians to adopt this innovative tool for improved practice efficiency.

2,837 uses
4.5/5.0
D
Dr. Emily Carter
Template Structure

Organized sections for comprehensive clinical documentation

(Compose entire note using UK English)
(Avoid including comments such as "not mentioned")
(Exclude any words in brackets)
(Omit any remarks about MyMedicare registration)
(Do not mention My Health Record)
(Avoid starting any sentence in the note with "The patient")
(Exclude e-mail addresses and phone numbers)
(Use Australian spelling for medications)
(Do not begin any sentence with "clinician" or "GP")
(Omit writing about patient details at the start of the text)
(Include negative findings in medical history and examination)
(Exclude profanity if used during the consult)
(Remove "-" at the beginning of sentences)
(Ensure every bullet point is followed by a sentence)
(Remove "Patient Details:" at the top of the note)
(Do not start the note with "C/O")
(Omit comments like "nil of note" if heading not mentioned)
(Exclude comments like "Not performed during this consultation")
(Do not include the sentence "Examination:"Not performed during this consultation")
(Never create your own patient details, assessment, diagnosis, differential diagnosis, plan, interventions, evaluation, plan for continuing care, safety netting advice, etc. Use only the transcript, contextual notes, or clinical note as a reference for the information you include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript or contextual notes, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)(Use as many sentences as needed to capture all the relevant information from the transcript and contextual notes.)
Verbally consented to the use of AI for note-taking as per Avant.
Offered discussion as to pros and cons and risks of data breach and explanation of how it works.
History:
1. [Comprehensive description for symptom 1]
[Symptom quality and severity]
[Symptom duration]
[Recent illnesses or events]
[Associated symptoms]
[Current treatments and their effects]
[Treatment planned for Issue 1 (only if applicable)]
2. [Comprehensive description for symptom 2]
[Symptom quality and severity]
[Symptom duration]
[Recent illnesses or events]
[Associated symptoms]
[Current treatments and their effects]
[Treatment planned for Issue 2 (only if applicable)]
3. [Comprehensive description for symptom 3]
[Symptom quality and severity]
[Symptom duration]
[Recent illnesses or events]
[Associated symptoms]
[Current treatments and their effects]
[Treatment planned for Issue 3 (only if applicable)]
4. [Comprehensive description for symptom 4]
[Symptom quality and severity]
[Symptom duration]
[Recent illnesses or events]
[Associated symptoms]
[Current treatments and their effects]
[Treatment planned for Issue 4 (only if applicable)]
5. [Comprehensive description for symptom 5]
[Symptom quality and severity]
[Symptom duration]
[Recent illnesses or events]
[Associated symptoms]
[Current treatments and their effects]
[Treatment planned for Issue 5 (only if applicable)]
Past history: (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Relevant past medical conditions, surgeries, hospitalisations, medications and ongoing treatments] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Possible medication side effects if explicitly mentioned]
Family history: (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Relevant past family history and social history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Examination: (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
(Do not include a comment saying "Not performed during this consultation")
[Findings from the physical examination, including vital signs and any abnormalities]
[Negative findings mentioned on examination]
[Only put examination findings in once] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Vital signs listed, eg. T , Sats %, HR , BP , RR , (as applicable)]
- [Physical or mental state examination findings, including system specific examination] (only include if applicable, and use as many bullet points as needed to capture the examination findings)
Plan:
[Summarise treatment plan for all problems detailed above]
Sample Clinical Note

Example of completed documentation using this template

Verbally consented to the use of AI for note-taking as per s10.ai. Offered discussion regarding the advantages, disadvantages, and risks of data breach, along with an explanation of its functionality.
History:
1. Persistent cough
The cough is dry and ongoing, persisting for the past three weeks. No recent illnesses or events noted. Associated symptoms include mild chest discomfort. Currently taking over-the-counter cough syrup with minimal relief. Plan to prescribe a short course of inhaled corticosteroids.
2. Headache
The headache is described as a dull ache, moderate in severity, occurring daily for the past two weeks. No recent illnesses or events. Associated symptoms include occasional nausea. Currently using paracetamol with partial relief. Plan to refer for a CT scan if symptoms persist.
3. Fatigue
The fatigue is severe and has been ongoing for the past month. No recent illnesses or events. No associated symptoms. No current treatments. Plan to conduct blood tests to rule out anemia or thyroid dysfunction.
4. Lower back pain
The pain is sharp and intermittent, lasting for the past two months. No recent injuries. Associated symptoms include stiffness in the morning. Currently using ibuprofen with some relief. Plan to refer to physiotherapy.
5. Rash on arms
The rash is itchy and red, present for the past week. No recent illnesses or events. No associated symptoms. Currently using antihistamine cream with some relief. Plan to monitor and consider dermatology referral if no improvement.
Past history:
Patient has a history of hypertension, managed with lisinopril.
Family history:
Mother has a history of type 2 diabetes.
Examination:
- Vital signs: T 37.0°C, Sats 98%, HR 72 bpm, BP 120/80 mmHg, RR 16 breaths/min
- Physical examination reveals clear lungs, no wheezing or crackles. Abdomen soft and non-tender.
Plan:
Prescribe inhaled corticosteroids for cough. Monitor headache and consider CT scan if no improvement. Conduct blood tests for fatigue. Refer to physiotherapy for back pain. Monitor rash and consider dermatology referral if necessary.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline the documentation process for healthcare professionals, ensuring accurate and efficient patient record-keeping. By incorporating high-search healthcare and clinical keywords, this template enhances the visibility and accessibility of patient notes, making it an invaluable tool for clinicians. It allows for detailed documentation of patient history, symptoms, past medical conditions, family history, and examination findings, ensuring that all relevant information is captured. The template also facilitates the creation of a clear and concise treatment plan, promoting effective patient management. By adopting this template, clinicians can improve their workflow, enhance patient care, and ensure compliance with documentation standards. Explore the benefits of this template to optimise your clinical practice today.
Frequently Asked Questions

Common questions about this template and its usage

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